Antipsychotic medication use on the rise in long-term care, thanks to COVID

This story is part of a series of articles on long-term care homes in the province using data from BC’s Long Term Care Directory. Find the other stories below:

• How individual care homes in the Fraser Valley are providing care for their residents—and where they are struggling.

• Compare long-term care homes from across BC.

Since the pandemic began, long-term care homes have increasingly turned to antipsychotic medications to manage the behaviour of residents, including those who have never been diagnosed with psychosis. That finding, shared in the latest Long-Term Care Directory, has BC’s Seniors Advocate concerned.

Provincewide, more than a quarter of long-term care residents who have not been diagnosed with psychosis are being given antipsychotic medications to manage their behaviour. That is up 8% from last year, and is the first increase after four years of decline.

Antipsychotics are a class of fast-acting medications that alter residents’ behaviour and which were initially developed for people with schizophrenia or psychosis. Unlike antidepressants, which focus on a person’s mood and tend to take longer to have an effect, antipsychotics almost immediately reduce agitation, restlessness, anxiety, and outbursts. That makes them a potentially popular behaviour modification tool in places like long-term care homes, even for residents who don’t have a diagnosis of psychosis or schizophrenia. However, they can also increase the risk of falls, infections, and strokes, among other negative side effects.

Before the pandemic, long-term care facilities across the province had begun work to reduce the proportion of residents being unnecessarily medicated with antipsychotics. A decade ago, the province found that half of long-term care patients were given antipsychotics (although this included patients who were prescribed the medication for psychosis). That was the highest proportion in Canada. With earlier research also showing that facilities with high antipsychotic use were three-times more likely to prescribe it, organizations like the BC Care Providers Association began a campaign to help facilities move away from medication use.

But the pandemic has slowed, if not reversed, those strides towards eliminating unnecessary antipsychotic medication use. In the Fraser Valley, antipsychotic medication use is widespread, but slightly lower than the provincial average: 22% of residents were given such drugs compared to 26% provincewide.

The reasons for the increase are varied, BC Seniors Advocate Isobel Mackenzie said, but may largely be linked to COVID and related issues, including staff shortages, isolation, visitation restrictions, and mask-wearing.

“People’s routines were up-ended,” Mackenzie said. “It would appear that the cumulative effect of all of that is that residents began to display behaviours that were addressed by medicating them with antipsychotics.”

But Mackenzie also said it’s possible behaviours didn’t change and that other factors like staffing caused long-term care homes more likely to turn to antipsychotics. The makeup of residents didn’t hasn’t changed significantly since the pandemic began, Mackenzie said—they weren’t much older, or more likely to have dementia or other severe cognitive impairments.

“Using other therapies to manage behaviors takes up staffing resources, so it’s also possible that the behaviors actually were no worse than in previous years,” she said. “It’s just that we didn’t have the time to spend with residents to de-escalate behaviours.”

Data from both the BCCDC and Long Term Care Directory show no significant correlation between COVID outbreaks and higher-than-average antipsychotic use. However, three Fraser Valley facilities—Agassiz Seniors Community, Glenwood Senior Community, and Langley Lodge—saw their medication use rise to early 2010s levels. Each had at least one COVID outbreak involving staff during the Long Term Care Directory data collection period.

Some facilities were able to continue to limit antipsychotic use despite significant outbreaks. At Menno Home, where dozens of residents and staff members tested positive, antipsychotic medication remained lower than a decade ago. The facility had one of the valley’s lowest rates of residents receiving antipsychotic medication.

Of course, there were other changes during that first COVID year. Inspections decreased significantly—likely because of how tightly locked down long-term care facilities were during the first few months of the pandemic. The average length of stay in long-term care also increased provincewide, although Mackenzie said we can’t be sure exactly why that happened.

“Is that reflecting the fact that people are maybe being placed in long-term care sooner than they need to be and they’re living there longer, or are we doing a better job of taking care of them so they’re living longer,” she said. “We don’t know that yet.”

Provincewide, the median length of stay increased 14% from 485 days to 555 days, or one and a half years. In Fraser Health, the median length of stay increased even faster. And in the Fraser Valley, the median length of stay is much longer than the provincial average: 819 days.

There was also a decrease in the proportion of employees who were vaccinated against the flu—although whether that was because of poor data collection or vaccine fatigue Mackenzie isn’t sure. (The Long Term Care Directory did not collect data on COVID-19 vaccination rates, as all long-term care employees must be vaccinated against the virus.) In the Fraser Valley, flu vaccine rates range between 93.8% at Abbotsford’s Oxford’s Senior Care and 9.7% at the nearby Valhaven Rest Home.

It remains to be seen what COVID-related changes will become permanent in long-term care homes. Mackenzie is expecting the number of inspections to return to normal this year, which will show up in the next Long Term Care Directory when it is released next December. She is less optimistic about the use of antipsychotic medications, however.

“I don’t think I’m going to see the drop that I would hope to see, to get us back to at least where we were pre-pandemic, which was still too high,” she said. “Once you start becoming accustomed to using medications on residents, it is a difficult habit to wean yourself from.”